Provider Demographics
NPI:1962608174
Name:GIFFORD, PENNY M (LCPC)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:M
Last Name:GIFFORD
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:PENNY
Other - Middle Name:M
Other - Last Name:SUTTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1371
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59806
Mailing Address - Country:US
Mailing Address - Phone:970-217-8686
Mailing Address - Fax:844-587-9638
Practice Address - Street 1:336 W. SPRUCE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802
Practice Address - Country:US
Practice Address - Phone:970-217-8686
Practice Address - Fax:844-587-9638
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4727101YP2500X
CO5992101YP2500X
MT101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT7168109Medicaid